ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
Attention-deficit/hyperactivity disorder (ADHD) is the most common psychiatric disorder among school-age children. Children with ADHD display the early onset of symptoms consisting of developmentally inappropriate overactivity, inattention, academic underachievement, and impulsive behavior.
Three different subtypes of ADHD may be diagnosed on the basis of the number and type of symptoms from each category, with subtypes referred to as either ADHD, inattentive type; ADHD, hyperactive-impulsive type; or ADHD, combined type. According to DSM-IV, symptoms of ADHD must be evident by age 7 years and have a minimum duration of 6 months.
Prevalence about 6%
DSM-IV Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
A. Either (1) or (2):
(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) Often has difficulty sustaining attention in tasks or play activities
(c) Often does not seem to listen when spoken to directly
(d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) Often has difficulty organizing tasks and activities
(f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) Is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) Often fidgets with hands or feet or squirms in seat
(b) Often leaves seat in classroom or in other situations in which remaining seated is expected
(c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be linked to subjective feelings of restlessness)
(d) Often has difficulty playing or engaging in leisure activities quietly
(e) Is often "on the go" or often acts as if "driven by a motor"
(f) Often talks excessively Impulsivity
(g) Often blurts out answers before questions have been completed
(h) Often has difficulty awaiting turn
(i) Often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Code based on type:
Attention-deficit/hyperactivity disorder, combined type: if the criteria A1 and A2 are met for the past 6 months
Attention-deficit/hyperactivity disorder, predominantly inattentive type: if criterion A1 is met but criterion A2 is not met for the past 6 months
Attention-deficit/hyperactivity disorder, predominantly by active-impulsive type: if criterion A2 is met but criterion A1 is not met for the past 6 months
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "in partial remission" should be specified.
Treatment:
? Stimulant medications have been found to reduce hyperactivity and improve attention span in 75 % of cases, the exact mechanism of action is not yet known, however, stimulation of cortical inhibition is suggested.
? Dextroamphetamine (in children > 3 years) and methylphenidate (> 6 years) in the morning and afternoon, doses are adjusted according to the response. Possible side effects include restlessness, tremor, sleep disturbances, growth inhibition (growth chart is needed) and dependence. ? Psychological treatment: individual and family therapy.
? Special education.
Prognosis: Hyperactivity improves with age in most cases. Some cases may continue in adult life; mainly those with low intelligence and major learning problems.
Conduct Disorder:
Severe and prolonged antisocial behavior in older children and teenagers.
Features:
• Aggressive behavior to other children.
• Destructive behavior
• Rebellion against parents
• Fire setting
• Lying
• Truancy
• Stealing
• Vandalism
? Etiology:
Adverse psychosocial situations play major roles e.g. broken family, unstable relationships, and poverty.
Treatment:
? Explore the environmental settings, social & family situations.
? Family and individual therapies.
? Haloperidol, lithium and carbamazepine have been found effective in controlling aggression and impulsivity.
Prognosis: Some teenagers continue to have antisocial behaviour after the age of 18 ( antisocial personality disorder ).

Oppositional Defiant Disorder: Defiant hostile ant negativistic behaviour, manifested by frequent:
• Loss of temper and anger outburst.
• Argument and refusal to comply with adults.
• Annoyance of others.
• Spiteful / vindictive behaviour. This disorder may coexist with ADHD, conduct and many other disorders. It’s occurrence increases in families with rigid parents, and intense moody children.

Treatment:
• Psychological (individual / family).
• Behaviour modification.
• Carbamazepine or lithium.





Elimination Disorders
A. Functional Enuresis B. Functional Encopresis

A. Functional Enuresis:
• Repeated involuntary voiding of urine after the age at which continence is usual (5 years) in the absence of any identified physical disorder.
• Nocturnal = bed wetting (at night).
• Diurnal = during waking hours.
? Primary enuresis: If there has been no preceding period of urinary continence for at least 12 months.
? Secondary enuresis: If there has been period of urinary continence for 12 months.
• It is likely to coexist with other psychological distress (e.g. sibling birth, parental discord…).
• No specific aetiology:

• Psychological squeals:
? Conflicts with parents
? Low self-esteem
? Social Rejection

Treatment:
? Search for and treat any possible physical disease e.g. repeated urinary tract infections (UTIs).
? Treat any associated emotional problem.
? Advice to parents (to avoid criticism…).
? Fluid restrictions before bedtime.
? Going to toilet before sleep.

-Behavioral therapy:
? (star chart technique)Record dry nights on a calendar and reward dry nights with a star and 7 consecutive dry nights with a gift.
• A bell and pad apparatus is helpful.
• Bladder training.
- Drugs:
• imipramine (a tricyclic antidepressant) 10 – 50 mg at night can reduce bed wetting significantly, but relapse rate after discontinuing treatment is high.
• desmopressin (an analogue of vasopressim) can be helpful but there is a risk of fluid overload.

Functional Encopresis:
• Repeated passing of feces into inappropriate places after the age at which bowel control is usual (4 years).
• Physical causes should be ruled out: e.g. chronic constipation with overflow incontinence.
• Stressful events at home may precipitate the condition.
• Assessment should include parental attitudes, emotional factors in the child, and the child’s concern about the problem.
• Behavior therapy (rewarding success and ignoring failure) often is helpful.
• Parental guidance and family therapy is required.

Separation Anxiety Disorders Excessive anxiety concerning separation from home or from major attachment figure for at least 4 weeks. Features:
• Excessive distress when separation is anticipated.
• Excessive worry about possible harm befalling or losing attachment figures.
• Reluctance to go to school because of fear of separation.
• Excessive fear when left alone
• Reluctance to sleep away from attachment figure.
The disorder may be initiated by a frightening experience or insecurity in the family, and is often maintained by overprotective attitude of the parents. Treatment: Psychological (individual / family) therapy. Behavior medication. Tricyclic antidepressants.
PHOBIAS IN CHILDREN Phobias are common, and usually normal in children. Common feared objects and situations include: animals, strangers, darkness, loud noisy voices. Most childhood phobias improve without specific treatment measures. However, parents should adopt a reasonable reassuring approach. Behavior treatment is required if phobia persists.
? School Phobia : Irrational fear of going to school associated with unexplained physical complaints such as headache, diarrhea, abdominal pain or feeling sick. Boys and girls are equally affected.
Complaints occur on school days (not in weekends). It occurs most commonly at the commencement of schooling, change of school or beginning of intermediate or secondary school.
Academic achievement is good or superior.
_ Possible precipitating factors:
? Separation anxiety (mainly in younger children) child wants to stay with a major attachment figure. Mothers are frequently overprotective.
? Minor physical illness.
? Upsetting event either at home (e.g. parental discord), or at school (e.g. criticism).
? General psychiatric problems e.g. low self - esteem and depression (in older children).
Treatment:
? Identify and treat possible causes.
? Early graded return to school (most helpful).
? Both parents should participate.
? School and teachers should be involved.
? Drugs have some role in reducing anxiety / or depressive features.